Methods and systems for minimally invasive endoscopic surgeries

ABSTRACT

The present invention relates to methods and systems for endoscopic fasciotomies. In certain embodiments such methods include dissecting tissue down to the fascia using an endoscopic dissector, lifting the fascia off tissue, vascular structures, muscle, and/or nerves, cauterizing and cutting the fascia using a bisector/bipolar device inserted through a cannula, retracting the cannula, and closing the incision site. A suction device introduced via the cannula may be used to apply suction to remove blood, tissue, irrigation fluid and/or other debris with the cannula in situ.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of, and priority to, U.S.Provisional Application No. 61/365,319, filed Jul. 17, 2010, entitled“Minimally Invasive Endoscopic Surgical Approach: Arterial VenousFistula Ligation—Excision and Arterial Venous Fistula Creation withSimultaneous Transposition” and U.S. Provisional Application No.61/420,092, filed Dec. 6, 2010, entitled “Methods and Systems forMinimally Invasive Endoscopic Surgeries,” both of which are incorporatedherein by reference in their entirety.

BACKGROUND

Minimally invasive surgery is the desired approach to reduce scarring,improve cosmesis, lessen postoperative pain, limit potential forinfection, and promote faster recovery. Minimally invasive approacheshave become the standard of care since laparoscopic cholecystectomy wasintroduced in the 1990s.

Traditional open techniques for certain surgical procedures, such asvascular access via arteriovenous fistulas for dialysis and/orfasciotomy, create long and/or multiple incisions and disfiguring scars.These open techniques place patients at high risk for infections,bleeding, painful surgical sites, poor wound healing, and/or functionalimpairment.

Thus, improved, minimally invasive endoscopic methods for arteriovenousfistula and/or fasciotomy surgeries, and improved surgicalinstrumentation for performance of those and other minimally invasiveprocedures, are needed.

SUMMARY

Embodiments of the present invention provide methods for minimallyinvasive endoscopic surgeries, including minimally invasive endoscopicarteriovenous (AV) fistula creation with simultaneous or stagedtransposition, minimally invasive endoscopic ligation and excision ofaneurysmal AV fistulas, and minimally invasive endoscopic fasciotomy.Benefits of the methods described herein relative to traditional opentechniques may include, for example, reduction in unsightly anddisfiguring scarring at a long incision site, faster wound healing,reduced pain, lower infection risk, and elimination of a subsequentsurgery.

Embodiments of the present invention also provide an improved surgicalsystem designed to perform the surgical methods described herein andother minimally invasive endoscopic procedures, particularly useful forthe upper extremities and smaller parts of the lower extremities.Benefits of the systems described herein relative to existing surgicalinstrumentation may include, for example, ease of use, reduced slippage,improved precision and results, and smaller surgical incisions.

The present invention relates to methods and systems for endoscopicfasciotomies. In certain embodiments such methods include creating anincision (e.g., of about 2 cm) at a proximal site and introducing ablunt tip trocar (BTT) to the incision. A cannula is inserted throughthe BTT, the cannula having an integrated C-ring and configured tointroduce various endoscopic devices, including an endoscope,bisector/bipolar and/or suction device. The method may includeinsufflating with low pressure CO₂ to create a visual field at the tipof the endoscope, dissecting tissue down to the fascia using anendoscopic dissector, cauterizing the fascia using a bisector/bipolardevice inserted through the cannula to make a small opening (e.g., 3mm), lifting the fascia off tissue, vascular structures, muscle, and/ornerves using, for example, a C-ring at the end of the cannula,cauterizing and cutting the fascia using the bisector/bipolar device,retracting the cannula, and closing the incision site. The suctiondevice may be used to apply suction to remove blood, tissue, irrigationfluid and/or other debris with the cannula in situ. As discussed herein,such procedures (and devices) have numerous benefits over traditionalprocedures.

Additional features and advantages of embodiments of the presentinvention are described further below. This summary section is meantmerely to illustrate certain features of embodiments of the inventions,and is not meant to limit the scope of the invention in any way. Thefailure to include, or the inclusion of, a specific feature orembodiment of any invention in this summary section should not beconstrued to limit any invention as claimed.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing summary, as well as the following detailed description ofthe embodiments, will be better understood when read in conjunction withthe appended drawings. For the purposes of illustrating the methods andsystems of the present application, there are shown in the drawingspreferred embodiments. It should be understood, however, that theapplication is not limited to the precise arrangements andinstrumentalities shown. In the drawings:

FIG. 1 shows an endoscopic system according to an embodiment of theinvention. FIG. 1A shows a blunt tip trocar, FIG. 1B an endoscope, FIG.1C a harvesting cannula, and FIG. 1D a bisector/bipolar device.

FIG. 2 shows a suction device according to an embodiment of theinvention. FIG. 2A shows the suction device alone and FIG. 2B shows thesuction device inserted into the harvesting cannula of FIG. 1C.

FIG. 3 shows a detailed view of the blunt tip trocar of FIG. 1A.

FIG. 4 shows a detailed view of the endoscope of FIG. 1B.

FIG. 5 shows a detailed view of the harvesting cannula of FIG. 1C withthe bisector/bipolar device of FIG. 1D inserted.

FIG. 6 shows a detailed view of the bisector/bipolar device of FIG. 1D,with an enlarged view of the handle.

DETAILED DESCRIPTION OF EMBODIMENTS Endoscopic Surgical Systems

Existing endoscopic vein harvesting systems were developed forharvesting of the saphenous vein or radial artery as conduits forcoronary artery bypass graft surgery. However, these and otherendoscopic devices have been applied to limited types of procedures. Inaddition, the existing devices are large and cumbersome to maneuver,even for their intended cardiovascular-related uses.

The anatomy of the upper extremity, and nerve-vein differentiation,large peripheral vein branches, and less CO₂/less pressure in the upperextremity, are of particular technical consideration in the endoscopicAV fistula surgical procedures described herein. Minimizing damage tothe intimal vein wall in transposition cases is of great importance.Thus, improved endoscopic devices, suitable for these and otherminimally invasive applications, are needed.

An improved endoscopic system, which is smaller, more precise, andeasier to use, as compared to existing endoscopic systems, is presented.Moreover, the improved endoscopic system described herein isparticularly well-suited for minimally invasive endoscopic procedures inthe upper extremity and/or smaller parts of the lower extremity,including, but not limited to, the novel minimally invasive endoscopicAV fistula, cardiovascular, and fasciotomy surgical methods describedherein.

In some embodiments, the invention provides an endoscopic system 100comprising a blunt tip trocar (BTT) introducer 110, an endoscope 120, aharvesting cannula 130, and a bisector/bipolar device 140, as shown inFIG. 1A-D. In some embodiments, the endoscopic system of the presentinvention includes a suction device 200, as shown in FIG. 2A-B.

As shown in FIG. 1A, the BTT 110 may include an inflatable occlusionballoon 114, a balloon inflation port 116 (which may be attached to asyringe or other device for filling with air), a CO₂ port 118 (to accessa constant low flow of CO₂, e.g., 8-10 mm Hg), and an endoscope/cannulaseal 112 to create a sealed tunnel. FIG. 3 shows a detailed view of thiselement, according to some embodiments, with like features havingsimilar numbering, and arrow indicating the insertion direction of theendoscope/cannula.

In some embodiments, a standard endoscope 120 may be used in theendoscopic system. An exemplary currently-available endoscope is a Storzendoscope. As shown in FIG. 1B, the Storz scope is preferably a 0°endoscope having a length 126 of about 26 cm to about 32 cm, preferablyabout 29 cm and a diameter/width of about 5 mm. The endoscope mayinclude an attachable clear conical tip 128 for dissection at a distalend and a site for attachment of a camera head 122 at a proximal end.Other features of the endoscope may include, for example, anillumination port 124 and a light source and/or a camera. Another viewof the endoscope is shown in FIG. 4, with like features having similarnumbering. As shown in FIG. 1B-C, the endoscope may be inserted into theharvesting cannula through opening 131 at the proximal end. These twoelements (endoscope and cannula) together are referred to herein as theendoscopic device.

Referring to FIG. 1C, the harvesting cannula 130 of the endoscopicsystem of the present embodiment preferably has a shaft 137 with alength equal to, or preferably less than, the length of the endoscope.For example, for use with an endoscope of length about 29 cm, as shownin FIG. 1B and FIG. 4, the cannula preferably has a shaft 137 length ofabout 20 cm to about 26 cm, preferably about 23 cm. In some embodiments,as shown in FIG. 1C, the cannula includes at its distal end (i.e., theend inserted into the incision site through the BTT) a C-ring 138 andone or more openings 139 for irrigation and/or CO₂ insufflation. At aproximal (non-inserted) end of the cannula, there is a handheld portion135, which may, for example, have an adjustable slider 136 coupled tothe C-ring for extending/retracting the C-ring, at least oneport/opening 132 for inserting the bisector or the suction device,and/or one or more syringe attachments (e.g., for saline irrigation 133and/or CO₂ insufflation 134). In some embodiments, the handheld portion135 is about 14 cm in length. Other handle lengths and/or features forcomfort, reduced slippage (e.g., for more stable use with wet gloves),and/or ease of use are contemplated. Preferably, the handheld portion135 is ergonomically correct. FIG. 5 shows a view of the cannula 130with bisector/bipolar device 140 inserted, according to an embodiment ofthe invention, with like features having similar numbering.

Referring to FIG. 1D, in some embodiments, a bisector/bipolar device 140(also referred to herein as the bisector) is used in the endoscopicsystem and can, for example, be inserted into the harvesting cannulathrough opening/port 132 as shown in FIG. 1C. The length 148 of thebisector/bipolar device is preferably related to, and may vary with, thelength of the cannula used. The bisector/bipolar device is preferablylonger than the harvesting cannula (e.g., long enough to extend throughthe distal end of the cannula to cut tissue, and sufficient on theproximal end to ensure that the handle does not dangle and bend, or cometoo close to the port 132). As shown in FIG. 1D, the bisector/bipolardevice 140 is about 40 cm to about 46 cm, preferably about 43 cm, inshaft 148 length, when used with cannula 130. The bisector/bipolardevice 140 may include a blade 150 and/or a cautery 152 at its distalend. The bisector/bipolar device 140 may also include at its proximalend a handle 144 with moveable slider 146 for actuating thescissors/cutting. The bisector handle preferably includes an electricalconnector 142. In some embodiments, the bisector handle 144 is betweenabout 11 cm and about 12 cm in length. As shown in FIG. 6, in certainembodiments, the bisector handle 644 may include, for example, threegrooves 645 for fingers. Other handle lengths and/or features forcomfort, reduced slippage (e.g., with wet gloves), ergonomiccorrectness, and/or ease of use are contemplated. For example, as shownin FIGS. 5 and 6, in some embodiments, the finger grooves 545/645 may betextured (e.g., with small raised semi-spherical bumps) and/or comprisea non-slip material (e.g., a rubber, silicone, or other grip material).Such a handle can prevent the slipping and spinning that can easilyoccur during surgical procedures using an existing, smooth-handledbisector/bipolar device.

Referring to FIG. 2A-B, in some embodiments, a suction device 200 isused in the endoscopic system, and can, for example, be inserted intothe harvesting cannula 230 through a port 232, as shown in FIG. 2B. Insome embodiments, the port 232 for the suction device is the same port132 that is used for the bisector device. The length 268 of the suctiondevice is preferably related to, and may vary with, the length of thecannula used. For example, the length of the suction device should besufficient to extend through the harvesting cannula and out the distalend to suction out contents, and be sufficient on the proximal end forease and safety of use (e.g., not too long/dangling around or tooshort/hugging the endoscopic device). The suction device 200 is about 29cm to about 35 cm, preferably about 32 cm, in shaft 268 length, whenused with cannula 130. In some embodiments, however, the suction devicemay be the same length as the bisector device (e.g., about 43 cm), forexample so that it may be used in conjunction with an existing cannula,which is larger than cannula 130. The suction device 200 may include ahandle 264 at its proximal end. In some embodiments, the suction devicehandle 264 is about 5 cm. In some embodiments, the suction device 200 isoptionally fenestrated at its distal end 270 (e.g., the distal 2 cm). Insome embodiments, the suction device 200 includes a proximal-endconnector 262 to wall suction tubing, which connects off the sterilefield to a suction canister. A thumb hole or other controllablevalve/opening 266 (e.g., a screw valve) may be provided at the proximalend to turn on/off and/or vary the amount of suction. Suction device 200allows the endoscopic field of vision to be cleared (e.g., of blood,debris, and/or fluid used to wash the endoscope) by suction, withoutdeflating the BTT 110 and removing the endoscopic device, as istraditionally done in the types of endoscopic surgeries discussedherein.

Endoscopic surgical systems discussed herein have a number of advantagesover existing saphenous vein-harvesting systems. For example, existingsaphenous vein-harvesting systems do not include any suctionfunctionality to clear the field of vision. If the field of view becomescovered with blood or debris, it needs to be removed. In some existinginstruments, the field of vision may be cleared, for example, byirrigating the distal end by spraying liquid toward the endoscope(similar to windshield wiper fluid). However, the liquid pools in theextremity, potentially blocking/blurring the visual field.

Thus, with current systems, when there is bleeding or a pool ofirrigation liquid (water, dirty saline, etc.) or debris (strands oftissue, adipose tissue, small blood clot, etc.) obstructing the visualfield, the BTT must be deflated and removed and the entire endoscopicsystem needs to be removed from the extremity. The wound is irrigatedfrom the incision site, blindly squirting irrigation solution into thewound. Then the contents (blood, debris, irrigation solution, etc.) are“milked” or rolled out by sequentially applying pressure externally(meaning on the skin from the outside), from the location of the distalend of the endoscope to the incision site (e.g., with a rolled up lappad). The debris and liquid are expelled out through the incision site.If there is internal bleeding, for example, from a side branch of thevein, or a small artery is injured and bleeding, external pressure isheld for a couple minutes to control hemostasis. Meanwhile, there is nodirect vision as the endoscope has been removed. Time is spent removingand re-inserting the endoscopic device, and each time it is re-inserted,it goes back to a slightly different position. Thus, still more time isneeded to re-situate/re-orient the device after re-insertion. Inaddition, even when anatomical landmarks are noted to mark the initialplacement of the endoscopic device (e.g., vein branches, adipose tissue,a bifurcation of the vein, a narrowed area, a tissue bulge, obviousbleeding, artery branch protruding), when re-inserting the device, thewrong plane could be opened, which may cause tissue damage and openareas for fluid to accumulate, leading to seromas, hematomas, and poorwound healing.

With the suction device of the present invention as part of theendoscopic system, the operative field can be cleared quicker and asource of bleeding can be more easily identified/recognized/located. Onecan irrigate, suction, and then cauterize the bleeder by simplyexchanging the suction device and the bisector device, all while keepingthe endoscope and cannula in situ and maintaining direct visualizationat all times.

Thus, it should be appreciated by those skilled in the art that havingsuction functionality in an endoscopic system makes minimally invasiveendoscopic surgical procedures more time efficient, safer, and savesblood loss (e.g., loss of blood due to removing and re-inserting theinstrumentation, the time it would take to irrigate then re-insert theendoscope, cannula, and bisector and find the previous area and thesource of the bleeding). It further allows for continuous stability ofthe operative site. With suction, the irrigation liquid can be easilyremoved and not be a cause of visual obstruction.

Suction may be used with the smaller cannulas described above inconnection with FIGS. 1C, 2B, and 5. Suction may also be used withexisting and future endoscopic systems, such as an existingsaphenous-vein harvesting system having a larger cannula, toaugment/improve the functionality and solve the problem of blood/fluidobstruction in those systems as well. In such embodiments the suctiondevice may be sized to extend the length of the cannula (e.g., 43 cm).

Another advantage of the endoscopic surgical systems discussed herein ismaneuverability. Existing saphenous vein-harvesting systems can beunnecessarily large/cumbersome and awkward for certain cardiovascularharvesting procedures, such as radial artery harvesting (upperextremity; forearm/arm) and harvesting smaller saphenous vein segments(partial extremity).

Radial artery harvesting is used as a conduit for coronary artery bypasssurgery. The radial artery is harvested from the distal area (wrist) tothe antecubital (inside of elbow) proximal end. Once the radial arteryis confirmed as a useable conduit, without compromising the arterialblood flow to the hand, the initial dissection is performed, identifyingthe radial artery with direct vision. The dissector (endoscope with thedissector tip) is introduced, separating the tissue surrounding theradial artery with bilateral vein attachments (small veins). The radialartery is separated anteriorly, posteriorly, laterally, and medially.Branches are isolated. The dissector is then exchanged for theendoscopic device (harvesting cannula and endoscope without dissectortip) with the bisector/bipolar device attachment. Branches arecauterized and cut. Any possible bleeding causes the field of vision tobe covered very quickly as the arterial flow is pulsatile and underpressure. Suction allows for the blood to be removed. The bleeding iscontrolled and removed with harvesting cannula in situ. The suction isexchanged with the bisector. Once the radial artery and subsequent veinare free from surrounding tissue a separate stab site is made at theproximal end and the radial artery is ligated ahead of the brachialjunction. The radial artery is then prepared by flushing withheparinized saline and all branches are secured. As described in detailbelow, the smaller device allows for more appropriate size suitability.The harvesting cannula with suction can be re-introduced and the priorradial artery donor site is inspected for any possible bleeders. Thesuction device allows for removal of irrigation solution to secure ahemostatic environment and then closure of the site distally. Theproximal site can be closed prior to final inspection to allow for a CO₂seal.

Typically, when harvesting a right radial artery the cardiac surgeon isstanding at the right side of the patient's chest (the patient is lyingon his/her back with arms straight out on arm boards in standard cardiacsurgical procedures). The existing saphenous vein-harvesting cannulathat may be used is long, and the radial artery from wrist toantecubital space (inside of elbow) is a much shorter distance. Thelarger cannula is hard to manage and difficult to balance with a narrowarm board. The smaller cannula described herein is more appropriatelysized and can eliminate contamination and obstruction from closesurroundings (e.g., a surgeon hitting instrumentation with his/her leftarm; if the surgeon is harvesting the internal mammary artery at thesame time the radial artery is being harvested, it is often thesurgeon's back and left arm that are in the radial artery operativefield with a high incident of hitting/contaminating). In some operatingrooms, the cardio-pulmonary bypass machine (perfusion machine), which isbulky (bigger than the patient), is also at the patient's right side.Thus, there may be very little room on the patient's right side for thesurgeon/harvester to access a right radial artery. The harvester may bein the surgeon's way; the surgeon may be in the harvester's way; inchesaway from both the surgeon and the person harvesting the radial arteryis the cardio-pulmonary bypass machine, which is the life line to thepatient. A shorter/smaller cannula device is more manageable and canhelp prevent/minimize the contamination that occurs when using a largerendoscopic device, and is therefore preferable for radial arteryharvesting.

The smaller cannula described herein may be preferable in certain caseseven for saphenous vein-harvesting, for which the larger endoscopicsystems were designed. For example, sometimes the cardiac surgery onlyneeds one or two pieces of saphenous vein, which can be taken from thelower leg or just a segment from the upper leg. If only a small segmentis needed, then the smaller cannula would be better suited to use forharvesting (whereas if 4-5 segments are needed for bypass, an existing,larger cannula may be better suited). For example, when harvesting asegment of saphenous vein in the lower leg (e.g., the knee down), theendoscopic harvesting device often ends up resting in the chest area.Thus, a smaller device is more manageable. The patient might be a“re-op,” meaning they had cardiac surgery before and are now returningfor another cardiac bypass surgery and all that remains is the lower legor only the upper thigh, so again the smaller cannula would be thebetter option. Another example is if a lesser saphenous vein is beingharvested. Lesser saphenous veins are difficult to harvest with thelarge endoscopic system. The lesser saphenous veins are anatomically onthe back side of the lower leg. The smaller cannula would be a better,more manageable option for this case as well.

The saphenous vein in the lower extremities can be harvested and used asa conduit for coronary artery bypass grafting. Once the saphenous veinis identified at the medial aspect of the knee area, the dissector(endoscope with dissector tip) is introduced through the blunt tiptrocar (BTT). All tissue is separated from the vein, anteriorly,posteriorly, laterally and medially, isolating all branches. Thedissector is then exchanged for the endoscopic device (harvestingcannula and endoscope without dissector tip) with the bisector/bipolardevice attachment. Branches are cauterized and cut with the bisector.The grooves on the bisector handle allow for better handling and grip. Aslight slip of the bisector while bovieing (cauterizing) can easilydamage the donor saphenous vein, compromising the integrity of the vein.Any possible bleeding, irrigation fluid, and/or debris can be removed bythe added suction device. Once all branches are isolated the vein can beremoved at the proximal end through a separate stab incision. The veinis ligated under and removed. The stab site can be closed. Theharvesting cannula can be re-introduced and the donor site of thesaphenous vein is irrigated and the contents suctioned out. Any bleedingcan be cauterized by exchanging the suction with the bisector. Oncehemostasis is confirmed the endoscopic device is removed and the site isclosed.

If more vein is required prior to ligating, the endoscope with dissectortip is flipped around and the knee (now considered the proximal end) isharvested down to the ankle The same procedure is performed.

If only a lower leg segment is required, there is the option to start atthe ankle and work most distally (ankle, medial fossa) to proximally(the medial aspect of the knee).

In harvesting from the knee to the ankle, the large endoscopic deviceand attachments/cords (camera, light source, bovie cord—the cauterizer,CO₂) all extend out the end of the harvesting device and can drape intothe abdominal area and often fall in the chest area. This causesdifficulty for the surgeon at the chest and cardio-pulmonary artery andvenous lines. The operating area is cluttered, leading to increasedchance of contamination. Thus for this case in particular, a smallerdevice of the embodiments described herein is more appropriate.

In harvesting both the radial artery and the saphenous vein, anyincidental injury caused by the cauterizing because of slippage of thehandle can damage the conduit, compromising the entire bypass surgery.The conduits become the blood flow to the heart, from the aorta to thedistal aspect of the stenosis, bypassing the stenotic area. Thus, thenon-slip features of the bisector/bipolar device handle 144, 544, 644described herein, are of particular importance for these procedures.

Suction and irrigation allow for better visual comprehension and lesschance of error.

Both conduits, a segment of saphenous vein and/or the radial artery(ies)used for coronary artery bypass surgery, should be in the bestpresentation in terms of integrity and structure. A smaller deviceallows for better manageability, and suction prevents the removal andre-insertion of the device, thus limiting the possibility of error andmore dissection down a false plane looking for the original site.

These are exemplary benefits and uses of the endoscopic surgicaldevices/systems described herein, and should not be construed aslimiting; other advantageous applications may easily be recognized bythose of ordinary skill in the art.

Endoscopic AV Fistula Surgeries

The incidence and prevalence of end-stage renal disease continues toincrease. Patients with end-stage renal disease require vascular accessfor dialysis. Some of these patients require temporary access whileawaiting a kidney transplant (assuming they are an acceptablecandidate), while others (e.g., those who are not transplant candidates)may require dialysis for the rest of their lives. Decisions about thetype of dialysis and the best method of access for dialysis requirecollaboration among the patient, nephrologist, and access surgery team.

Primary autogenous arteriovenous (AV) fistulas are the preferred meansof vascular access for hemodialysis. In patients who choosehemodialysis, an AV fistula is often created preemptively, allowing timefor the fistula to mature pending usage. Indeed, the National KidneyFoundation Kidney Disease Outcomes Quality Initiative guidelines supporta “fistula first” doctrine.

Traditional venous transpositions use an open technique generally asfollows. If the anatomy permits, surgically created vascular accessstarts distally on the upper extremity. The radial-cephalic path is themost distal access option. In the upper arm, the brachial artery isanastomosed to either the basilic or cephalic veins. Initially, a deepcephalic-vein-to-brachial-artery fistula is created through a horizontalincision (e.g., 3 to 5 cm) near the antecubital fossa.

In many patients, the cephalic vein in the upper arm is superficialenough for direct cannulation for hemodialysis. After a period ofmaturation (e.g., four to six weeks), the AV fistula is assessed forpalpable thrill, audible bruit, and the ability of the vein to beaccessed through the skin for dialysis, which are indicators of asuccessful AV fistula. If necessary, ultrasound may be used to assessfistula size and depth.

If the vein (whether cephalic or basilic) remains too deep, the patientis scheduled for a second surgery for transposition. Vein transpositionis also referred to as superficialization, as the vein is dissected fromthe deep tissue and embossed directly under the skin to allow easieraccess of the hemodialysis catheters. This is done through a separatevertical incision (referred to as the conventional open incision) fromthe antecubital fossa to the axillary area. Patients with deep veins orextensive adipose tissue typically require this two-stage surgery: thefirst stage completes artery and vein anastomosis (the fistula), and thesecond completes the transpositioning of the vein.

An open AV fistula transposition surgical incision is long (about 20 to25 cm in length, from the antecubital space to the axillary area) andunsightly. Patients who undergo this conventional procedure are at riskfor infections, bleeding, and painful surgical sites. Each surgicalprocedure lends itself to scarring and potential deformities. Many ofthese patients also have comorbidities, such as diabetes, predisposingthem to poor wound healing. Renal-failure patients are at particularlyhigh risk for complications from any surgery, and immunosuppressanttherapy places kidney transplant recipients at even greater surgicalrisk.

Over time, chronic-renal-failure patients may require revisions ordevelop painful aneurysmal fistulas that necessitate removal of the AVfistula. An AV fistula may fail for various reasons, including low orpoor blood flow, failure to mature, excessive pain (e.g., due torepeated dialysis needling), a sclerotic vein, and/or a thrombotic vein.Failure can be disheartening to a patient who realizes that anothersurgery is required. In addition, patients with functioning renalallografts (post-renal transplant) frequently request fistula removal,as these fistulas can be painful, disfiguring, and a reminder of thepatient's experience on hemodialysis. Traditionally, these ligations andexcisions are completed through incisions that extend the length of theaneurysmal fistula, which also carry a risk of infection, bleeding,painful surgical sites, and scarring.

The minimally invasive endoscopic methods and systems described hereprovide an alternative approach for AV fistula creation/transpositionand ligation/excision.

The novel minimally invasive endoscopic surgical methods discussedherein include: (i) harvesting of a deep basilic or cephalic vein forcreation of a brachial-basilic or brachial-cephalic AV fistula, withsimultaneous transpositioning; (ii) harvesting of a deep basilic orcephalic vein for transposition of an existing brachial-basilic orbrachial-cephalic AV fistula; and (iii) ligating and excising ananeurysmal radial-cephalic, brachial-cephalic, or brachial-basilic AVfistula from the upper or lower arm. As will be appreciated by those ofskill in the art, although surgical procedures may be performed with anynumber of endoscopic devices, the devices and systems disclosed hereinwith regard to FIGS. 1-6 are particularly well suited for performingsuch procedures.

In certain embodiments, the harvested vein is transpositioned todirectly under the skin, then anastomosed to the brachial artery,creating an AV fistula accessible for hemodialysis. This replaces thetraditional two-stage surgery with a single-stage surgery and eliminatesthe long vertical incision associated with a conventional open AVfistula transposition.

In other embodiments, an aneurysmal AV fistula is ligated and excisedendoscopically, thereby minimizing incisions.

As compared to traditional open AV fistula surgeries, these proceduresreduce body disfigurement, scarring, post-operative pain, and potentialfor infection. Following the procedure disclosed herein to harvest adeep upper-arm cephalic vein, for example, the patient is left with onlytwo small scars. This procedure also eliminates repeated or stagedsurgery and promotes faster recovery and improved wound healing andpatient body image. These procedures are described in greater detailbelow.

I. Primary Creation with Simultaneous Endoscopic Transposition of UpperExtremity Basilic or Cephalic Vein for Arterial Venous Fistula

In some embodiments, an exemplary method for primary AV fistula creationwith simultaneous endoscopic transposition of an upper extremity basilicor cephalic vein is as follows. A 2-cm incision is made at theantecubital area. The artery and intended vein are identified. A blunttip trocar (BTT) is introduced to the incision. A balloon on the BTT isinflated to create a seal, and low pressure CO₂ insufflation is started.An endoscopic device (endoscope and cannula) is introduced through theBTT. The endoscope is advanced with a conical tip for dissection. Thevein is passed superiorly, inferiorly, medially, and laterally, and veinbranches are isolated. The C-ring at the end of the cannula is exchangedfor (e.g., retracted) and replaced with a bisector/bipolar device, whichis advanced through the cannula. The vein branches are cauterized andcut/bisected. A 1-cm stab site is made at a proximal end of the vein(axillary area). The vein is grasped and pulled out through the stabsite. The bisector/bipolar device is removed, and the vein is cannulatedand flushed with heparanized saline. The cauterized side branches of thetranspositioned vein are tied off/reinforced (e.g., with 4-0 silk ties).A tunneler device is passed from the distal to the proximal incision.The vein is loaded into the tunneler. The tunneler is passed with thevein from the proximal to the distal incision. Vascular clamps areapplied. The vein is anastomosed to the artery end. Vascular clamps areremoved. The resulting AV fistula is assessed for thrill, whichindicates a successful AV fistula creation. The incision sites areclosed.

II. Endoscopic Staged Transposition of Upper Extremity Cephalic Vein forArterial Venous Fistula

In some embodiments, an exemplary method for endoscopic stagedtransposition of an upper extremity cephalic vein for an AV fistula isas follows. A 2-cm incision is made through the primary incision (madewhen the AV fistula was initially created) at the antecubital area. TheAV fistula is identified and isolated. A vascular clamp is placed abovethe anastomosis on the vein. A cut is made on the vein side and the veinedge is secured with silk tie. The silk ties are clamped or tacked to adrape so as not to drag the vein into the wound. A BTT is introduced tothe incision. A balloon on the BTT is inflated to create a seal, and lowpressure CO₂ insufflation is started. An endoscopic device is introducedthrough the BTT. The endoscope is advanced with a conical tip fordissection. The vein, which may be within deep layers of adipose tissue,is passed superiorly, inferiorly, medially, and laterally, and veinbranches are isolated. The C-ring is exchanged for (e.g., refracted) andreplaced with a bisector/bipolar device, which is advanced through thecannula. The vein branches are cauterized and cut/bisected. A 1-cm stabsite is made at a proximal end of the vein (axillary area). The vein isgrasped and pulled out through the stab site. The bisector is removedand the vein is cannulated and flushed with heparanized saline. Thecauterized side branches of the transpositioned vein are tiedoff/reinforced (e.g., with 4-0 silk ties). A tunneler device is passedfrom the distal to the proximal incision. The vein is loaded into thetunneler. The tunneler is passed with the vein from the proximal to thedistal incision. Vascular clamps are applied. The vein isre-anastomosed, vein to vein-artery (AV fistula site) end to end.Vascular clamps are removed. The resulting AV fistula is assessed forthrill, which indicates a successful AV fistula creation. The incisionsites are closed.

III. Endoscopic Excision of an Aneurysmal Arterial Venous Fistula in theUpper Extremity (Radial-Cephalic, Brachial-Cephalic, orBrachial-Basilic)

In some embodiments, an exemplary method for endoscopic excision of ananeurysmal AV fistula in the upper extremity (radial-cephalic,brachial-cephalic, or brachial-basilic) is as follows. A 2-cm incisionis made through an existing scar from the initial creation of the AVfistula. The anastomosis of the artery and vein is identified andisolated. A vascular clamp is placed on the vein side of theanastomosis. The vein is divided from the anastomosis. The arterial stubis over-sewn. The first couple of centimeters of vein are dissected out.Blood is expressed from the vein lumen. The vein edge is tied,preferably twice, with 2-0 silk tie. The silk ties are tacked to a drapeso as not to drag the vein into the wound. A BTT is introduced to theincision. A balloon on the BTT is inflated and low pressure CO₂insufflation is started. An endoscopic device is introduced through theBTT. The endoscope is advanced with a conical tip for dissection. Thevein is passed superiorly, inferiorly, medially, and laterally, and veinbranches are isolated. The C-ring is exchanged for (e.g., retracted) andreplaced with a bisector, which is advanced through the cannula. A 1-cmstab site is made at a proximal end of the aneurysmal vein. The vein isgrasped and a vascular clamp is placed around the vein. The vein isexcised and the vein specimen is removed. The proximal vein stub isover-sewn, and the proximal clamp is removed. The wound is irrigatedwith antibiotic solution. Incisions are closed (e.g., with 3-0 vicrylthen 4-0 biosyn). Dressings are applied and the extremity is wrapped(e.g., with ACE™ wrap). The wrap is preferably left on for 24 hoursunless the patient has finger numbness, pain, or finger swelling, andthe extremity is preferably kept elevated. Heavy lifting is notrecommended.

As will be appreciated by those of skill in the art, the foregoingprocedures are exemplary, and procedures including fewer or additionalsteps, or performing such steps in a modified order, or other variationsare also within the scope of the present invention. For example, foreach of the above procedures, a block with Monitored Anesthesia Care(MAC) may be used unless the patient is under general anesthesia. Also,in some embodiments, transpositioning does not include a secondstab-grab incision.

In some embodiments, a tunnel is created through adipose tissue with thecannula, eliminating any use of a separate tunneler device. After thevein is pulled out at the proximal end, flushed with heparinized saline,and inspected/examined for leaks, the branches are tied off. Then,instead of using the tunneler device, the endoscope with dissector tipis passed through, distal to proximal (in the same fashion thattunneling is performed with the tunneler device), just under the skin,making a tunnel. Then the endoscope with dissector tip is withdrawn andreplaced with the endoscopic device (harvesting cannula and endoscopewith dissector tip removed) with bisector/bipolar device attachment. Thebisector is advanced through from distal to proximal following the samesubcutaneous path. Once the bisector is through to the proximal end,there is a tiny opening on the C-ring to thread a suture. The end of thesuture is tied to the vein, then pulled through the endoscopic device,carefully advancing the vein through under the skin. Preferably thereare no clips, just suture ties used on the vein. These embodimentseliminate the use of a separate tunneler instrument fortranspositioning, making the procedures entirely endoscopic except forthe anastomosis (sewing the vein end to the side of the artery), whichis typically performed under direct vision at the incision site.

Endoscopic Fasciotomy Surgeries

Compartment syndrome is a limb threatening condition which can be foundwherever a compartment can be anatomically present. This includes, forexample, the hand, forearm, upper arm, abdomen, buttock, and lowerextremities (both upper and lower legs as well as the feet). Compartmentsyndrome can occur when the muscle compartment exceeds the perfusionpressure of the tissue. The fascia covering creates a restrictiveelement, thereby inhibiting any expansion of the affected anatomicalarea. Compartment syndrome is the compression of underlying tissue,vascular compression and/or occlusion, nerve damage, muscle compressionand restriction, leading to tissue ischemia and necrosis.

Compartment syndrome can be caused, for example, by long bone fractures,burns (chemical, thermal, and/or electrical), bleeding in enclosedspaces, external or crush injuries/events, envenomation from snakebites, thrombotic or embolic events (e.g., deep vein thrombosis),traumatic injuries, exercise, prolonged extremity immobilization,vascular injury, massive fluid resuscitation in burn or trauma victims,and/or morbid obesity. Compartment syndrome can be chronic in certainathletes from exercise-induced or repetitive impact injuries.

A fasciotomy is the treatment for compartment syndrome. The fasciotomyis performed to relieve underlying tissue pressure, and enable betterperfusion and blood flow. A fasciotomy is performed to prevent tissuedeath. The fascia tissue can vary in terms of density, thickness, andelasticity.

Traditional fasciotomies are open fasciotomies that involve longincisions made longitudinally from proximal to distal through the skinand tissue to the internal fascia of the affected area. Thus, an openfasciotomy can be a source of morbidity and lead to potential infectionsdue to exposed underlying tissue, poor wound healing, skin grafts,disfigurement and extensive scarring, and decreased and/or permanentfunctional impairment.

Such issues with traditional fasciotomies due to compartment syndromehave left orthopedic surgeons looking for a better method to decompressthe tissue without making large incisions. Other current methods include“semi-blind” passage of long scissors to cut the fascia and the use ofarmy-navy retractors, in chronic compartment syndrome patients. Nothingis known to have been attempted on acute compartment syndrome patients.Problems with the existing semi-blind techniques include potential riskfor incomplete fascia division, nerve injury/impingement, and/orunrecognized fascial defects.

In addition, because there is no “designated” device or appropriateinstrument to use for fasciotomy procedures, orthopedic surgeons haveattempted various alternative techniques. For example, some have used agynecological speculum (the instrument that is used for obtaining a PAPsmear for women), whereas others have used a shoulder arthroscope (ascope for the shoulder). Use of various instruments intended for otherprocedures demonstrate that there is a need and a setting for improvedmethods and devices for performing fasciotomies.

Once a fasciotomy has been determined to be the surgical intervention,the option of performing the procedure endoscopically can be considered.Embodiments of the present invention provide endoscopic fasciotomyprocedures that may be easily completed for preventing or treatingcompartment syndrome. Instead of opening a leg or arm through thetraditional open incision, such procedures can be performed through asmaller incision, while providing complete visualization. Endoscopicfasciotomy may be useful, for example, in situations where transport toa higher level of trauma facility may be needed and endoscopicfasciotomy could provide an initial intervention. More generally, theendoscopic fasciotomy approach of the present invention may be useful insituations in which there is a need for space for swelling, but an opentechnique would increase morbidity.

Thus, embodiments of the minimally invasive endoscopic surgical methodsof the invention further include, for example: (iv) endoscopic legfasciotomy and (v) endoscopic arm fasciotomy. These procedures aredescribed in greater detail below.

Fundamental knowledge of the anatomy and the underlying tissue, as wellas the anatomical landmarks and structures, is assumed for theseprocedures (including the fascia and muscles, as well as the nerves andvascular tissue). Briefly, each lower leg has four muscle compartments(anterior, lateral, superficial posterior, deep posterior). The thighhas four compartments (anterior, medical, lateral and posterior). Thebuttock is composed of three major muscles, each within its owncompartment, the gluteus maximus muscle, gluteus medius muscle, and thegluteus minimus muscle. The upper arm has two compartments, anterior andposterior. The forearm has two compartments, anterior and posterior.

IV. Endoscopic Leg Fasciotomy

In some embodiments, an exemplary method for endoscopic leg fasciotomyis as follows. An initial incision is made approximately 2 cm above themost proximal site. The tissue is then dissected down to the fascia.Once enough space is created then the endoscopic device is inserted.Once identifying tissue is clearly visualized, then the endoscopicdissector (endoscope with dissector tip) is advanced longitudinally tothe desired distal site. Once enough space has been created (e.g.,tissue plane dissected) then the dissector tip is removed (e.g.,unscrewed) and the endoscopic device (harvesting cannula and endoscopewithout dissector tip) with the bisector/bipolar device attachment isinserted. Appropriate landmarks (such as muscles, nerves, and connectivetissue of the fascia) should be identified. The bisector/bipolar devicepenetrates the fascia, cauterizing enough to make an initial opening ofapproximately 3 mm. The C-ring cups or grasps the edge of the fascia,which is preferably lifted off of the underlying tissue, vascularstructures, muscle, and nerves. As the C-ring creates a counter tensionat the crotch of the fascia opening, the bisector/bipolar device isadvanced, cauterizing and cutting the fascia. As the bisector/bipolardevice is advanced, care is taken to maintain hemostasis. Suction can beapplied by exchanging the bisector/bipolar device with the suctiondevice, as described herein.

Once the fascia is opened, then the endoscopic device is retracted tothe insertion site and slowly advanced for inspection and then toseparate individual muscle groups as needed. The procedure is repeatedfor as many compartments of fascia as are necessary to be opened.

In performing a fasciotomy of the thigh/upper leg, for example, the 2-cmincision may be at a site near the buttock with the endoscopicfasciotomy proceeding along the femur toward the knee. In the lower leg,the 2 cm incision may, for example, be at a site near the knee (lateralor medial) with the endoscopic fasciotomy proceeding along thetibia/fibula toward the lateral/medial malleolus.

V. Endoscopic Arm Fasciotomy

In some embodiments, an exemplary method for endoscopic arm fasciotomyis as follows. An initial incision is made approximately 2 cm in lengthat the most proximal area. Dissection to the fascia is obtained. Theendoscopic device is inserted into the incision and the dissector tipcreates an open plane as it is advanced to the distal site. Thedissector tip is then removed and the endoscopic device (harvestingcannula and endoscope without dissector tip) with the bisector/bipolardevice attachment is inserted. Once the fascia is clearly identified, asmall opening, approximately 3 mm (enough to open the fascia for thebisector to be advanced) is created. As with the leg fasciotomy, thefascia is cupped by or grasped with the C-ring, creating countertension. Then the bisector/bipolar device is advanced in synchrony withthe harvesting cannula, cauterizing the fascia while cutting it open.Once the distal area is reached, then the bisector/bipolar device iswithdrawn. If further areas of the fascia need to be cut, then theendoscopic device is retracted to the insertion site and the sameprocedure is applied.

Each of the above fasciotomy procedures is typically performed in theoperating room; however, if properly prepared and if equipment isavailable, fasciotomies can be performed in the emergency room. Theseendoscopic procedures can be performed under a regional block anesthesiaor general anesthesia, taking into consideration the presentingsituation.

Each fasciotomy allows room for swelling and expansion of the underlyingtissue. Assessment of the tissue for perfusion, pallor, pain, pulses,and/or paresthesia is preferably performed. If more extensive expansionis required then the endoscopic fasciotomy may be converted to an openfasciotomy, or an open fasciotomy may be performed following theendoscopic fasciotomy.

An appropriately sized endoscopic system with suction, such as thatdescribed herein, is preferred for these minimally invasive endoscopicfasciotomy surgeries, allowing for complete visualization, minimizingpotential internal damage, and permitting the best possible outcomes.However, an existing endoscopic device, such as a saphenousvein-harvesting device, may also be used for the fasciotomy proceduresas described above.

Additional uses of the minimally invasive approach described herein arealso contemplated, particularly for any endoscopic surgical proceduresin which small incisions are desirable. The smaller endoscopic systemdescribed herein may be more appropriately sized, easier for theharvester to use, and may minimize error.

EXAMPLES

The invented surgical methods presented herein are further described inthe following examples, which do not limit the scope of the inventionset forth in the claims. The following examples describe clinical casesthat have been treated according to some embodiments of the inventedmethods. The surgeries described in the examples were performed using anexisting saphenous vein-harvesting system. However, in some embodiments(such as those in the upper extremities), an improved endoscopic systemsuch as that described above, which is smaller, more precise, and easierto use, is preferred for these surgical methods.

Example 1 Transposition and Creation of Brachial-Cephalic AV Fistulawith Endoscopic Vein Harvesting

The initial antecubital fossa incision was about 2 cm in length. Oncethe brachial artery and the cephalic vein were identified, an endoscopicdevice was introduced through the same incision and utilized to harvestthe cephalic vein from the most distal to proximal end.

The endoscopic device was equipped with in-line tools. With the conicaltip attached to a 7-mm scope, the cephalic vein was followed on a levelplane. Insufflation with low-pressure CO₂ created a visual field thatenabled the identification of vein branches. The branches werecauterized with a bisector tip providing hemostatic control. Harvestingincluded dissection of adipose tissue from the vein and avoidance of thenerve as it was visualized. The concave shape of the endoscope's C-ringbasined the vein, allowing the surgeon to run the vein from its proximalto distal end while inspecting for any further dissection. This alsoallowed for careful assessment to ensure all branches had been ligatedand divided.

A 2-cm counter-stab incision was then made at the proximal end to allowfor the vein to be reined out. The vein was inspected and flushed withheparinized saline. Divided venous-side branches were reinforced with4-0 silk ties. The patency of the vein was evident. A standard AV grafttunneling device was used to tunnel the vein from the proximal to thedistal incision in the subcutaneous plane. The harvested vein was placedin the inner aspect of the tunneler and passed back through from theproximal end to the distal incision. The transpositioned vein was thenanastomised to the side of the brachial artery. Venous and arterialclamps were removed; a palpable thrill was appreciated. Hemostasis wasobtained, and the incisions were closed using absorbable sutures. Theneed for a second surgery was eliminated. At eight weeks, the fistulawas mature and able to be cannulated for hemodialysis.

Example 2 Transposition of Brachial-Basilic AV Fistula with EndoscopicVein Harvesting

The patient presented with a brachial-basilic AV fistula in situ that,while adequate in size, was too deep for hemodialysis needle punctureaccess. The patient was morbidly obese, had comorbidities that woulddelay wound healing, and was at risk for complications. The minimallyinvasive approach to endoscopic harvesting of the basilic vein ensued.

The antecubital incision from the creation of the AV fistula was openedand the anastomosis site identified. The arterial flow was clamped onthe venous side. An endoscopic device was introduced and the undistendeddeep basilic vein harvested. A 2-cm counterincision was made about 17 cmfrom the insertion site at the proximal side. The basilic vein wasreined out and all branches were ligated. After patency had beenestablished, the basilic vein was tunneled back through the subcutaneousplane. The transpositioned vein was re-anastomised back to the originalAV fistula site. Venous and arterial clamps were removed; a palpablethrill was appreciated.

When the patient returned for a two-week post-operative follow up, thevein was palpable throughout with a thrill and the incisions werewell-healed. The patient was instructed to return in four weeks for AVfistula anastomosis maturation assessment.

Example 3 Radial-Cephalic AV Fistula Ligation and Excision

The patient had a renal transplant and complained of an unsightly andpainful radial-cephalic AV fistula. A 2-cm incision was made through theoriginal fistula-creation scar. The radial-cephalic AV fistulaanastomosis was dissected and ligated, halting the arterial bloodsupply. An endoscopic device was introduced through the same incision.The conical tip was used to separate the thickened fistulous vein fromsurrounding tissue. Insufflation with CO₂ was used to create a visualfield. All identifiable branches were cauterized and bisected. A 2-cmstab incision was made approximately 15 cm from the distal incision. Theaneurysmal vein was reined out through the stab-site incision and tiedoff. The incisions were irrigated and closed. An ACE™ wrap was placedover the site for 24 hours with instructions to remove if any numbnessor tingling in the fingers occurred.

The patient returned approximately one week later. There was no reportof any numbness or tingling in the fingers and no swelling. Distalpulses were intact, as was distal perfusion.

Example 4 Brachial-Cephalic AV Fistula Ligation and Excision

The patient had a renal transplant and complained of an unsightly andpainful brachial-cephalic AV fistula. As in Example 2, the incision wasestablished through the original creation-site scar at the antecubitalfossa. The cephalic vein was ligated near the arterial anastomosis andthe aneurysmal cephalic vein harvested endoscopically. A counterincisionwas made at the proximal end approximately 15 cm from the distal site.The vein was reined out through a 1-cm incision, tied off, and excised.The wound was irrigated and closed. An ACE™ wrap was applied. Two weekslater, the patient had minimal swelling and no complaints of any pain ordiscomfort. Distal pulses and perfusion were intact.

While there have been shown and described fundamental novel features ofthe invention as applied to the preferred and exemplary embodimentsthereof, it will be understood that omissions and substitutions andchanges in the form and details of the disclosed methods, devices, andsystems may be made by those skilled in the art without departing fromthe spirit of the invention. Moreover, as is readily apparent, numerousmodifications and changes may readily occur to those skilled in the art.Hence, it is not desired to limit the invention to the exactconstruction, procedures, and operations shown and described and,accordingly, all suitable modification equivalents may be resorted tofalling within the scope of the invention as claimed. It is theintention, therefore, to be limited only as indicated by the scope ofthe claims appended hereto.

1. A method of performing a minimally invasive endoscopic fasciotomy in an upper or lower extremity, the method comprising: creating an incision of about 2 cm at a proximal site; introducing a blunt tip trocar (BTT) to the incision; introducing a cannula through the BTT, the cannula having an integrated C-ring and configured to receive an endoscope having a tip therein; insufflating with low pressure CO₂ to create a visual field at the tip of the endoscope; dissecting tissue down to the fascia using an endoscopic dissector inserted through the cannula; cauterizing the fascia using a bisector/bipolar device inserted through the cannula, creating an opening of about 3 mm; lifting the fascia off at least one of tissue, vascular structures, muscle, and nerves using the C-ring; cauterizing and cutting the fascia using the bisector/bipolar device; retracting the cannula; and closing the incision site.
 2. The method of claim 1, further comprising: introducing a suction device having a distal end through the cannula so that the distal end is proximate the visual field; and activating suction through the suction device, clearing the visual field.
 3. The method of claim 2, further comprising introducing irrigation fluid, wherein activating suction removes the irrigation fluid.
 4. The method of claim 1, wherein the endoscopic dissector is an endoscope having a dissector tip.
 5. An endoscopic surgical device for use in endoscopically performing a fasciotomy on fascia in an extremity of a patient, the device comprising: a blunt tip trocar (BTT) for insertion into an incision in the extremity; a cannula for insertion through the BTT, the cannula having a distal end to be inserted into the patient; a bisector/bipolar device sized to fit into the cannula, the bisector/bipolar device for use in cutting and cauterizing the fascia; and an endoscope having a distal end and providing a visual field at the distal end, the endoscope sized to fit into the cannula to permit cutting and cauterizing of the fascia under endoscopic visualization without an open surgery.
 6. The endoscopic surgical system of claim 5, further comprising: an endoscopic suction device sized to fit into and extend to the distal end of the cannula to provide suction at the cannula distal end to remove debris without removing the cannula.
 7. The endoscopic surgical system of claim 5, wherein the suction device has a handle and a body sized to fit into the cannula, wherein the body is about 32 cm in length.
 8. An endoscopic surgical system for use in endoscopically performing a fasciotomy on fascia in an extremity of a patient through an incision of about 2 cm, the device comprising: means for providing suction; means for dissecting tissue; means for viewing the fascia through the incision for permitting bisection of the fascia without an open surgery; means for bisecting the fascia; means for introducing the means for suction, means for bisecting, means for viewing and means for dissecting into the patient through the incision, the means for introducing having a distal end; and means for creating a sealed tunnel at the incision and receiving the means for introducing, wherein the means for providing suction is further for providing suction at the distal end of the means for introducing to remove debris without removing the means for introducing.
 9. The endoscopic surgical system of claim 8, wherein the suction means has a length of about 32 cm.
 10. The endoscopic surgical system of claim 8, wherein the suction means includes a fenestrated distal end.
 11. The endoscopic surgical system of claim 8, wherein the means for viewing is an endoscope and the means for dissecting is the endoscope having a dissecting tip.
 12. The endoscopic surgical system of claim 8, wherein the means for introducing includes a port for receiving the suction means. 